Neurology & Pain Management Coding Alert

Spinal anatomy knowledge, coding smarts a must for successful claims.

In a PM practice, it might be easy to lose sight of the most basic elements of pain management. To keep this from occurring, it never hurts to get a refresher on all the basics of coding for the symptoms and treatments of pain.

That’s just what HEALTHCON 2024 attendees got from Jessyka Burke, BHSA, CPC, COSC, CASCC, during her presentation “Taking the Pain out of Pain Management Coding.” During the session, Burke guided attendees through the basics of pain, how to recognize the symptoms, and code accordingly.

Check out what she had to say in this pain primer.

Know Spinal Anatomy

The most important anatomic region for any PM coder to know intimately is the spine, a “column of nerve fibers that are responsible for sending and receiving messages from the brain to the rest of the body,” said Burke, coding specialist at Cascade Orthopaedics in Auburn Washington. “Nerve roots are used to transmit information regarding what is being felt and what is being directed to move.”

Burke said that four out of five Americans will experience back pain at some time in their lives, and back pain is the second most common reason people visit their general physician.

There are three main regions of the spine and two lesser ones. Starting from the top of the head, they are:

• Cervical (C1-C7)
• Thoracic (T1-T12)
• Lumbar (L1-L5)
• Sacrum (S1-S5)
• Coccyx (tailbone)

These areas combine to form the spine, which consists of an average of 33 bones in most adults, Burke explained.

Remember Discs, Soft Tissue Spinal Areas

The spinal area isn’t all bone, however. There are also other important areas that you’ll need to familiarize yourself with in order to code pain and PM correctly.

“Intervertebral [spinal] discs are flat, round cushioning pads that sit between each vertebra or back bone,” explained Burke. “There is also soft tissue in the spinal region like tendons, which connect bones together and add strength to joints.”

Know Acute, Chronic Definitions

In order to properly code for pain and PM, you need to be sure on the definitions of acute and chronic pain.

“Chronic pain is considered a disease itself. It can be influenced by environmental and psychological factors and is resistant to most medical treatments,” explained Burke.

Some of the most common types of chronic pain include:

• Lower back pain
• Arthritis
• Headaches
• Fibromyalgia
• Neuropathic pain
• Cancer pain
• Pelvic pain
• Post-surgical pain
• Complex regional pain syndrome (CRPS)

Characteristics of chronic pain include:

• Cause: Often unknown or ongoing
• Duration: Persists for more than three months
• Treatment: Underlying cause and pain disorder, which often involves a PM program

Acute pain, on the other hand often results from disease, inflammation, or injury to tissues. “It can happen suddenly and is usually treatable within three to six months,” explained Burke.

Some of the most common causes of acute pain include:

• Injury: Cuts, scrapes, sprains, burns
• Surgery: Postoperative pain
• Infections: Ear, throat, urinary tract
• Acute illness: Appendicitis, gallstones, fractures
• Inflammation: Tendinitis, bursitis
• Muscle strain
• Menstrual cramps

Encourage Px Pain Diary

When a patient does suffer from chronic pain, your PM specialist will often be the physician providing the pain relief program. These patients are prime candidates for pain diaries, which can be very useful in a PM program.

What is it? Patients use a pain diary to document their pain experiences. This can help in the understanding of the pain’s patterns, triggers, and intensity.

Pain diary elements: Here are some of the elements you might want to consider when formulating a pain diary template:

• Date and time: Whenever the pain occurs, note the date and time.
• Intensity: Use a pain scale, such as 0-10, to gauge the pain’s severity.
• Location: Specify the pain’s location.
• Description: Detail the type of pain. (stabbing, dull, pounding, burning).
• Duration: Note how long the pain lasts, and if it is constant or intermittent.
• Triggers: Identify elements that seem to trigger or worsen the pain, such as activities, foods, stressors, or environmental factors.
• Relief: Keep a record of any medications, treatments, or activities to alleviate the pain. Also, note how effective each is at lessening pain.
• Activities and impact: Note how pain impacts overall quality of life: daily activities, sleep, mood, etc.
• Additional symptoms: Record symptoms that accompany the pain, such as nausea, fatigue, dizziness, shortness of breath, etc.
• Emotional state: Note emotional state when experiencing pain, such as angry, depressed, happy, etc.

Put the Puzzle Together

Providers and coders at a PM practice must work together to puzzle out how to code your patient’s pain, and the services provided, Burke explained.

The operative note is key; this is where providers “tell the story, what happened today,” said Burke. What is the reason you made the decision for the treatment plan? Also, they need to note how comorbidities would affect each treatment plan.

Burke encouraged providers to try to “create a connection with your coders. Communicate, and don’t be afraid to ask questions.”

Once the providers put their work in, it’s time for the coder to “dig in — dissect — the entire [operative] note,” said Burke. Coders are also encouraged to communicate with their providers and ask questions if they are unsure of something.

“Also, remember every patient is different,” reminded Burke. She ended by reminding coders to always be current on three topics:

• Anatomy
• Terminology
• Payer policies.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC